aDepartment of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, CanadabInstitute of Social and Preventive Medicine (IUMSP), University Hospital Center and University of Lausanne, SwitzerlandcDivision of Nephrology and Hypertension Consultation, University Hospital (CHUV), Lausanne, Switzerland
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We have read with interest the recent article by Christensen et al.  that reviewed the use of electronic monitoring of adherence in patients with hypertension. The authors have elegantly shown that electronic devices such as Medication Event Monitoring System (MEMS; AARDEX Ltd., Zug, Switzerland) or Intelligent Drug Administration System (IDAS II; Bang and Olufsen Medicom, Struer, Denmark) enable the measurement of patient adherence to antihypertensive drugs and hence may help to improve blood pressure (BP) control.In our opinion, one aspect not emphasized by the authors is that electronic monitoring of drug adherence also enables healthcare professionals to make more rational therapeutic decisions in their daily practice . Indeed, electronic monitoring offers an accurate and ‘real time’ follow-up of medication taking [3–5]. With these data in hand, clinicians can discuss medication taking with their patients and analyse reasons of nonadherence. Knowing what the compliance is, health professionals are in a better position to decide whether the intervention has to be focused on the medical treatment itself or on the patient's adherence by proposing, for example, some reminders such as taking medication at clock times in order to reinforce their adherence consequently. Furthermore, clinicians can assess with such data the real link between the daily medication taking and treatment outcomes  (Table 1).Today, when a physician is facing a patient with uncontrolled BP, he/she will generally assume that the prescribed drugs are either inefficient or suboptimally dosed. Consequently, he/she will adapt the treatment accordingly by either increasing the doses, changing drugs or adding a new antihypertensive compound. Would the physician's reaction be different if he/she knew the patient's adherence? Probably yes, because with electronic monitoring, the clinical situation becomes little bit clearer (Table 1). If the patient has an uncontrolled BP and his adherence to drug therapy is perfect, a change in treatment is indeed required (Table 1, case A1). However, if the same patient is nonadherent, changing therapy or increasing dosages could be a mistake and actually counterproductive. In this situation, the clinician should first discuss and understand the reasons of nonadherence in order to be able to propose some strategies to help the patient in his daily drug intake (Table 1, case A2). A change in treatment may be necessary only once adherence is improved. Therefore, electronic monitoring may help clinicians to make rational therapeutic decisions .It is to support this hypothesis that the ExTRA study , a 12-month pragmatic cluster randomized controlled study among community pharmacists and physicians' networks, was conducted. Patients allocated to electronic monitoring achieved a better BP control. However, the impact of electronic monitoring decreased with time essentially due to physicians abandoning the compliance monitoring with time. Of note, physicians had the opportunity to continue or to stop electronic monitoring depending on the results of office BP and drug adherence, and patients who were continuously monitored had a greater likelihood of having a controlled BP . These data would therefore support the idea that knowing drug adherence improves our capacity to manage patients, but the tools should be improved in order to be of easier access to clinicians in their daily practice.In our opinion, electronic monitoring is not only a tool to assess and support patient adherence but also may help clinicians to take more rational therapeutic decisions based on objective data on drug adherence and, eventually, to improve BP control.